Our Privacy Policies and Forms

Notice of Privacy Policies

At His Branches Health Services, we are committed to treating and using your personal health information responsibly.

New York State law requires a physician to maintain a medical record for each patient which accurately reflects the evaluation and treatment of a patient. Unless otherwise provided by law, medical records must be retained for at least six years. Obstetrical records and records of minor patients must be retained at least six years and until the minor patient reaches the age of nineteen.

It is important to understand that all individually identifiable information about your health, condition, treatment, or payment for your health care is considered “Protected Health Information” (PHI) under the Federal Health Insurance Portability and Accountability Act (HIPAA).

HIPAA requires us to maintain the privacy of your protected health information and to provide you with a notice describing how we may use and share your information, as well as our legal responsibilities and your rights are regarding your protected health information. We are required to follow the privacy practices described in this notice; however, we reserve the right to change the terms of this notice at any time. If changed, the provisions of the new notice will become effective for all protected health information maintained at His Branches Health Services. The new version will be posted in our waiting area, and the effective date will be clearly stated in the introduction of the document. You may also request a copy of the updated notice from our office staff.

  • Click here to read and print our Privacy Policies.

Authorization Forms

Once you’ve read our Privacy Policies using the link above, please fill out, sign, and return the following forms to our office along with all of the other New Patient Information, using the download link below:

  1. Notice of Privacy Policies Acknowledgment Form (2 copies: 1 for you, 1 for us)
  2. Message Authorization and Privacy Rights
  3. 3rd Party Disclosure
  • Click here to read, print, and sign the Authorization Forms.

Designating a Health Care Proxy

Finally, we’d like to know who to contact if we ever have to make decisions about your health care when you aren’t well enough to make them for yourself.

  • Click here for more information from the NYS Department of Health.
  • Click here to print and fill out your Health Care Proxy form.